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�wM <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> OE OFFICE USE: <br /> Telephone: (209) 466--6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 77-jcyl1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued X17 <br /> (Complete In Triplicate) permit to construct <br /> al application is made in compliance with San Joaquin <br /> Application is hereby made to tdescribed. Thisoapp Health District or a pLocal Health District. <br /> and/or install the work herein <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin <br /> �-s � CENSUS TRACT <br /> JOB ADDRESS/LOCATION Phone <br /> � r <br /> Owner's Name _ city <br /> � Address '� r <br /> License # 2—do <br /> hone �7 <br /> Contractor's Name <br /> _NDITION DESTRUCTION /� e <br /> TYPE OF WORK (Check): NEW WELL DEBI' lI p�REPAIR / Il PUMP REPLACEMENT I� 1 <br /> x PUMP INSTALLATION <br /> Other / / <br /> PIT PRIVY <br /> � J SEWER LINES OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL'�FIELD � PUBLIC DO STIC WELL <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> � ! Cable Tool Dia. of Well Excavation Ar <br /> Industrial - Drilled Dia. of Well Casing fi <br /> Domestic/private Driven Gauge of Casing ' <br /> Domestic/public <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation Rotary TYPe of Grout <br /> — Cathodic Protection y <br /> Other _ Other Information <br /> Disposal r Surface Seal Installed B <br /> ! -�—Geophysical <br /> PUMP INSTALLATION: <br /> Contractor � H.P. <br /> Type of Pump <br /> e <br /> PUMP- REPLACEMENT: / / State Work Done 3; <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: DescribeWell meter <br /> Material and Procedure <br /> lth <br /> rict <br /> I hereby agree to comply with all laws and regulations <br /> f the <br /> ecSall ction.uin LoWithcal inaFFTEENtDAYS <br /> and the State of of my woo pertaining to orregulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health above <br /> District <br /> WELL DRILLERS REPORT e well and notify <br /> them <br /> befnd beli full WILL CALL FORng the well in uAeGRO eINSPECTION <br /> information is tru to th NbesI o CTIkN° $ sa <br /> PRIOR TO GROU TITLE <br /> SIGNED <br /> SE S <br /> DRAW -PI T PLAN ON REVERIDE <br /> FOR DEPARTMENT USE ONLY <br /> t DATE <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p INAL INSPECTION f <br /> P . INSPECTIONDAT <br /> ECTION BY DATE <br /> A <br /> INSPINSPECTION BY` � <br /> I 3/76 2M <br /> 1 <br /> H 142 <br /> ev• 1-7' <br />